Basic Information
| Provider Information | |||||||||
| NPI: | 1245383850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCAVOY | ||||||||
| FirstName: | RICHARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ROUTE 108 | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037427492 | ||||||||
| FaxNumber: | 6037426762 | ||||||||
| Practice Location | |||||||||
| Address1: | 237 ROUTE 108 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037496686 | ||||||||
| FaxNumber: | 6037503174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1494 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0802560Y0NH01 | 01 | NH | ANTHEM | OTHER | 30010824 | 05 | NH | MEDICAID |